Shalhoub brings obsessive compulsive disorder to light
By Adele Slaughter, Spotlight Health, and medical adviser Stephen A. Shoop, M.D.

On the hit USA Network show Monk, Tony Shalhoub plays a detective with obsessive compulsive disorder (OCD) who solves crimes by noticing the tiniest of details. But in real life it's the big picture about the disorder that inspires Shalhoub. "I hope that the show will make it okay to talk about OCD," says Shalhoub, "as well as help people trust that having it doesn't make them freakish, and perhaps have sympathy for others who have the tendencies."

Shalhoub, who is one of the show's producers, believes he understands OCD better than most.
"Even though I wouldn't categorize myself as obsessive-compulsive, there are things I do that someone might consider idiosyncratic," says Shalhoub. ""I'm not an authority on OCD so I don't want anybody to think that I know that much. But I think everybody has certain things that they get fixated on. I tend to be a bit of a clean freak, I think. I'm a little bit of a germaphobe. Not to the extent that Monk is, perhaps."

But many Americans are exactly like Monk.

Perceiving the problem

Approximately one in 40 to one in 50 people have a full-blown case of OCD.

"We like to stress that OCD is a neuropsychiatric disorder, it is a disorder caused by the brain," notes Dr. Jeffrey Schwartz, research professor of psychiatry, UCLA School of Medicine. "Because of these brain imbalances you get intrusive thoughts and urges, which are the hallmarks of the condition."
One of the common misconceptions about OCD is that those afflicted are potentially dangerous.

"OCD is characterized by persistent, intrusive thoughts, usually regarding the possibility of harm or danger to oneself or others," says Dr. Bruce Hyman, director, OCD Resource Center of South Florida. "These thoughts are accompanied by compulsions or repetitive acts intended to mitigate the danger or harm of these thoughts and ideas. These thoughts are not usually related to any real harm."

"A typical age of onset for OCD is late adolescence, early adulthood," says Schwartz. "And it generally affects males and females equally. Classically, patients will have clear-cut symptoms before they are 30."
Shalhoub's character develops OCD after the murder of his wife.

"It is plausible that a person could have a mild case and then something happens "death or depression" and it flares up into a clinical disorder," confirms Schwartz.

"About 15% of the population has symptoms that cause distress, but not to such an extent that it causes an impairment," says Schwartz. "OCD causes a significant impairment in daily functioning."
Obsessive thoughts include ideas like:

Fears of contamination.
Imagining causing harm to self or others.
Imagining losing control of aggressive urges.
Intrusive sexual thoughts or urges.
Needing to confess, tell, or ask. Actions done in an obsessive, repetitive manner which indicate a person is involved in obsessive thinking include:
Washing hands.
Checking things - the stove, the door.
Touching, tapping, counting.
Putting objects in order.
Hoarding or saving.
Repeating.
 

Generally OCD is ego-dystonic, which means people know that these thoughts are inappropriate and experience them as unwanted. People with OCD genuinely want their obsessions to go away.

Mind over matter

Most OCD experts agree that treatment should be a combination of cognitive-behavioral therapy and medication.

Cognitive-behavioral therapy involves learning strategies for mastering symptoms and is usually done with a therapist, although people with mild symptoms have been able to effectively treat themselves.

The most commonly used medications for the treatment of OCD are selective serotonin reuptake inhibitors (SSRIs), which include Paxil, Luvox, Prozac, and Zoloft.

Schwartz, who authored Brain Lock, has developed four steps to help patients with OCD learn to manage and control their obsessive behaviors.

Step 1: Re-labeling "You use mindfulness or the impartial observer to look at your inner experience with a dispassionate perspective, as if you were reading your own mind," says Schwartz. "You are calm, objective, and dispassionate. You want to label your thoughts accurately and move from 'I feel like I need to wash,' to 'This thought "I feel I need to wash," is an obsessive thought.'"

Step 2: Re-attribute "Obsessive thoughts are unwanted thoughts that keep occurring because of an underlying biological problem. In the brain, you can see a lock between the orbital frontal cortex and the caudate nucleus. 'It keeps bothering me because of this brain lock, because this is my disease state.' Patients train themselves to say, 'This is my medical condition, OCD talking.'

Step 3: Re-focus "In this step, the effort is to generate the mental force to change the brain circuitry and to shift out of the compulsive behavior into an adaptive behavior," says Schwartz. "That is hard to do because the feelings follow you. You have to change your behavior with the feelings still there. Through mental effort and different actions you generate new mental activity."

Step 4: Re-value "When you use the first three steps on a regular basis you begin to revalue," says Schwartz. "I call this step progressive mindfulness, meaning you experience the experience as OCD. It's a deep re-labeling, so that rather than experiencing the thoughts as yourself, you feel them as obsessions."

Entertaining hope

While there is no cure for OCD, the prognosis for those who can manage their thoughts is excellent. The most successful patients become experts on their own disease.

"It's called 'insanity with insight' or 'the doubting disease,'" says Hyman. "It is a living hell for those who have it."

In most cases of OCD, patients experience a great deal of shame around their thoughts and behaviors. Accepting and understanding the disease helps empower patients to fight OCD and rewire their brain circuitry.
"The thing I like about Monk is that he's trying so hard," says Shalhoub. "I thought there was a risk playing this character, because he could be a most annoying human being, but he's aware of his neuroses and he's trying to overcome them. That is the key - that he's trying to make himself better, because he knows he's good at being a detective."

"OCD is a really serious problem and we don't mean to exploit it in any way," says Shalhoub. "I'm not presuming this show is going to be a cure-all for people with this problem" it's not what we're setting out to do" this is entertainment, it's not a medical show, and I'm sure we take a lot of dramatic license" but helping people understand OCD would be a great by-product of the show."